Charles River Insurance: Welcome

5 Whittier Street, Framingham, MA 01701
Main: 508.656.1400, Fax: 508.656.1499
Hours of Operation: M-F, 8:00 a.m. - 5:00 p.m. EST
Available weekends and nights by appointment
info@charlesriverinsurance.com

Report a Claim

	As our company grew, it was important to choose an insurance broker who had the knowledge and experience to provide complete, comprehensive insurance coverage for our specific needs. Charles River Insurance met all of these requirements. They are involved from the beginning stages of evaluating potential new building acquisitions to working with our lenders developing insurance solutions for each property’s unique risk. Working with Charles River Insurance continues to be one of our best business decisions.
	Brian Poitras, Principal Calare Properties, Inc.

Client Services

Automobile Loss Notice

Date of Loss and Time:

Contact Information (insured)

First Name:
Last Name:
Address:
E-mail:
Home Tel #:
Bus Tel # (+ area code):
Social Sec #:
Where to contact:
When to contact:

Loss

Location of Accident: (include city and state)
Authority Contacted:
Report #:
Violations/Citations:
Description of Accident:	include as much information as possible

Your Vehicle

# of vehicles		Year:
Make:		Model:
Plate Number:		State:

Owner's Name & Address

First Name:
Last Name:
Address:
Home Tel #: (+ area code)
Bus Tel #: (+ area code, ext)
Driver's Name & Address (check if same as owner)
First Name:
Last Name:
Relation to insured:
Date of Birth:
Driver's License#:	State:
Home Tel #:
Bus Tel #: (incl ext
Purpose of Use:
Used with permission?	Yes No
Describe Damage:
Estimate Amount:
Where can vehicle be seen?
When can vehicle be seen?
Other insurance on vehicle:
Property Damage
Describe Property: (if auto, year, make, model, plate#)
Other vehicle/property insurance?	Yes No
Company or agency name:
Policy #:
Owner's Name & Address
First Name:
Last Name:
Home Tel #:
Bus Tel #: (incl ext)
Other Driver's Name & Address (check if same as owner)
First Name:
Last Name:
Home Tel #:
Bus Tel #: (incl ext)
Describe Damage:
Estimate Amount:
Where can damage be seen?

Who is Injured?
Were you (the insured) injured?	Describe your injuries:
Yes No

Others Injured?
Name & Address		Extent of Injury
	Phone (area+num)
	Pedestrian?
	Other Driver?

	Phone (area+num)
	Pedestrian?
	Other Driver?

	Phone (area+num)
	Pedestrian?
	Other Driver?
Witnesses or Passengers
Name & Address		Other (Specify)
	Phone (area+num)
	Your Vehicle?
	Other Vehicle?

	Phone (area+num)
	Your Vehicle?
	Other Vehicle?

	Phone (area+num)
	Your Vehicle?
	Other Vehicle?

IMPORTANT: Please take a moment to make sure, before hitting the SUBMIT button at the end of this form, that your entries are correct. You can do so by using the scroll bar to the right of this screen. Using the back button of your browser (because of varying browser configurations) may cause information to be lost.


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